Drug Administration and Venipuncture

OBJECTIVES

After studying this chapter, the student will be able to:

1. List the universal precautions to be taken during drug administration.

2. Differentiate between the apothecary and metric systems of measurement.

3. Identify the common medical abbreviations used in medication administration.

4. List the components of a medication order and the method of documenting drug administration.

5. List and explain the methods of drug administration.

6. Describe the equipment necessary for drug administration.

7. Describe the differences in the packaging of parenteral drugs.

8. Identify the sites for administering drugs.

9. Define venipuncture and the role of the radiographer in this procedure.

10. Describe the best site selection and preparation for venipuncture.

11. Discuss the care of patients with an intravenous line and how to discontinue an intravenous site.

KEY TERMS

Bolus: A single, large quantity intended for therapeutic use

Buccal: In the mouth adjacent to the cheek

Contraindication: Any symptom or circumstance that renders use of a drug inadvisable

Enteral: Within the gastrointestinal tract

Extravasation: The escape of fluid from a vessel into tissue

Infusion: The introduction of a drug slowly through the blood stream

Intra-arterial: Within the artery

Intra-articular: Into the cavity of the joint

Intralesional: Into the center of a lesion

Intracardiac: Into the chambers of the heart

Oral: By mouth

Parenteral or parenterally: Refers to administration of a drug by penetrating the skin

Rectal: Inserted into the rectum

Sublingual: Under the tongue

Topical: Designed for or involving local application and action (on the skin)

The professional radiographer who administers drugs is expected to know the safe dosage, the safe route of administration, and the limitations of the drug to be administered. All potential hazards of any drug that is incorrectly or unsafely administered must also be known. If drug administration errors are made because of lack of knowledge, the person who administers the drug is legally liable. Radiologic technology students who are permitted to administer drugs must adhere to the specific ethical and legal guidelines established for drug administration. The student must be supervised by a licensed professional, professional liability coverage must be adequate, and the student must also demonstrate competency before performing drug administration without supervision.

The position of the American Society of Radiologic Technologists is that “venipuncture falls within the profession’s Scope of Practice and Practice Standards and that it shall be included in the didactic and clinical curriculum with demonstrated competencies of all appropriate disciplines regardless of the state or institution where such curriculum is taught.”

STANDARD PRECAUTIONS IN DRUG ADMINISTRATION

All drugs (medications) are potentially harmful. The radiographer must completely understand the implications of any actions when administering drugs or assisting with drug administration. Never administer a drug that has not been specifically ordered by a physician. All health care workers who administer drugs must understand the intended action, contraindications, side effects, and potential adverse effects of any drug they administer.

The radiographer must adhere to the following five rights of drug administration at all times:

1. The right patient (P)

2. The right drug (D)

3. The right amount or dose (A)

4. The right route (R)

5. The right time (T)

Using the acronym PDART, one can easily remember the five rights.

Other precautions that must be taken before any drug is administered are:

1. Read all labels carefully before drawing up or pouring a drug. Check the name, strength, and dosage of the drug.

2. If a drug contains a sediment or appears to be cloudy, do not use until the pharmacist approves the drug.

3. Check the expiration date of the drug on the label. If that date has passed, do not use.

4. Do not use drugs from unmarked or poorly marked containers. Discard them.

5. Measure exact amounts of every drug used. If medication is left over, do not replace it in the container; discard it according to institutional policy.

6. Drugs must be stored in accordance with the manufacturer’s specifications. No drug should be stored in an area where temperature and humidity vary greatly or are extreme.

7. If a medication is a liquid to be poured, pour away from the label.

8. Do not combine two drugs in a syringe without verifying their compatibility with the pharmacist. If in doubt, do not combine!

9. Before selecting a medication, check the label of the container three times: before taking it from storage, before pouring it or drawing it up, and after it has been prepared for administration.

10. When drawing up medication for someone else to administer, show that person the label of the drug container. Have the person who will do the administration verbally confirm the name of the drug.

11. When approaching a patient who is to receive a drug, ask the patient for two identifying qualifiers (name and birth date). Do not accept the fact that a patient answers to what is thought to be the correct name. An anxious patient may respond incorrectly. Read the name label on the patient’s wrist, if available.

12. After identifying the patient, explain about the drug and how it will be given.

13. A drug history of allergies must be taken before any drug is administered.

14. The radiographer must not administer a drug that was preprepared. All drugs and contrast media must be prepared and administered (or overseen) by the same person.

15. Report and document any drug that the patient refuses to take.

16. Document any drug administered immediately according to department procedure.

17. Do not leave unattended a patient who may be having a drug reaction!

18. A patient who has received a sedative, hypnotic, antianxiety, or narcotic analgesic drug must not be allowed to drive home.

19. A child who has received a medication and is sleeping may not leave the department until fully awake.

20. Patients should be observed for 1 hour before leaving the department alone after receiving any drug.

Special considerations that must be watched for when administering drugs are further delineated in Table 16-1.

SYSTEMS OF DRUG MEASUREMENT

The metric system of measurement has been adopted in most countries as the official standard; in the United States, however, its use is recommended but not required.

It is used in most medical settings in this country, but the apothecary system of measurement is also used. This means that anyone who administers drugs must understand and be able to use the two systems interchangeably. Household measurements are not commonly used in medical facilities, and only those most commonly used will be mentioned. The radiographer who plans to administer drugs must learn to convert from metric to apothecary measurement, depending on how the physician’s order is written.

The metric unit of measure is the liter (L), which contains 1,000 milliliters (mL) or the approximate cubic metric equivalent of 1,000 cubic centimeters (cc). The unit of weight is the gram (g). Kilograms (kg), milligrams (mg), and micrograms (mg) are used in health care. The kilogram is 10,000 g or, in nonmetric terms, 2.2 lb.

Medical symbols and abbreviations are used in health care on a daily basis, and any person who works in this arena is expected to understand them. A list of
the most common abbreviations and equivalencies appears in Table 16-2. The radiographer must not make up abbreviations or administer a drug unless there is a complete understanding of correct dosage.

TABLE 16-1 Special Considerations When Administering Drugs

Age Group	Physiologic Changes	Precautions
Pregnant women	Many drugs cross the placental barrier. Drug effects depend on fetal age and can result in harm to the fetus.	Drugs during pregnancy must be avoided or administered only to women who absolutely require treatment. If in doubt, inform patient’s physician of possible pregnancy before administering any drug.
Infants	Lack well-developed muscle mass; lack the protective mechanisms of older children and adults. Skin is thin and permeable; stomachs lack mucous barrier; temperature control is poor; they become dehydrated easily and have immature liver and kidneys that cannot manage foreign chemicals.	Only persons educated in drug administration to infants must administer medications to them.
Breastfed infants	May have all drugs in maternal circulation transferred to colostrum and breast milk.	Mothers who are breastfeeding may be advised by the physician to cease breastfeeding for a prescribed time if they are to receive radioisotopes or radiation. All other drug therapies must be evaluated because they may harm the infant. A detailed history must be taken, and no drugs should be administered without establishing that they will not harm the infant.
Pediatric patients	At 1 year of age, liver metabolizes more rapidly than in adults; renal function may be more rapid than in adults. Standard dosage depends on child’s weight or body surface. Topical drugs are more easily absorbable through the skin.	Children are not small adults! Physiologic differences vary, and only those experienced in medicating children must administer drugs to them! Topical drugs and solutions, including antiseptics, can cause poisoning in children. Cleanse only with soap and water.
Elderly patients	Blood-brain barrier is more easily penetrated, with increasing rate of dizziness and confusion. Reduced baroreceptor response increases hypotensive effects of some drugs. Liver size, blood flow, and enzyme production decrease, increasing the half-life of some drugs and leading to possible toxic reactions. Increased adipose tissue in abdominal area may lead to toxicity from fat-soluble drugs. Decreased renal blood flow and filtration decrease elimination of drugs from the body. Slower gastric emptying time and increase in pH of gastric juices increase risk of gastric irritation.	Drugs affecting the central nervous system and cardiovascular system must be given with extreme caution. Patients must be monitored closely and assisted with ambulation to prevent falls. Do not allow elderly patients who have been given drugs to leave the area unattended.

TABLE 16-2 Common Standard Medical Abbreviations

PO = by mouth	ac = before meals
IM = intramuscular	pc = after meals
IV = intravenous	hs = at bedtime
STAT = at once	PRN = as necessary
VO = verbal order	q = every
SC or SQ = subcutaneous	qd = every day
ID = intradermal	tid = three times a day
bid = twice a day	q2h = every 2 hours
gtt = drop	mL = milliliter
cc = cubic centimeter

THE MEDICATION ORDER AND DOCUMENTATION

Licensed physicians, dentists, podiatrists, and optometrists can prescribe, dispense, and administer drugs. Under specific circumstances that vary from state to state, nurse practitioners, physician assistants, and pharmacists may order and dispense drugs.

No health care worker may prescribe or administer drugs that are not ordered by a person licensed to do so. In health care settings, an order must be dated, written, and signed by the physician. If the patient is to be cared for in a medical facility, as in a diagnostic imaging department, the order is written on an order sheet or on a computerized order sheet (Fig. 16-1).

The written request for an examination using intravenous (IV) contrast media should include the medical necessity for the examination, the type of contrast to be used, and the manner in which the procedure will be performed. Medical necessity for the procedure is demonstrated by including the signs and symptoms of the patient’s problem, a relevant history, the current diagnoses, and a specific reason for the procedure requested. This request must come from the patient’s physician.

When a radiographer, acting under the supervision of a radiologist, administers a contrast medium to a patient, it must be recorded in the patient’s medical record. The time of day, the name of the contrast, the dose, and the
route of administration must be included in the documentation. The radiographer, or whoever administers the medication, must also sign the chart for identification purposes. The supervising physician then countersigns the entry. The documentation of administration of contrast media will vary according to institutional protocol. In most cases, the use of contrast media is stated in the radiologist’s report following the procedure.

FIGURE 16-1 A computerized order sheet.

If a patient is to be discharged with a prescription, it will be written on the physician’s personal order form. The order will include the following:

The patient’s full name, the date, and the time the order is written

The date and time(s) that the drug is to be taken

The generic or the trade name of the drug

The dosage and the route of administration

The physician’s signature

An example of a physician’s order for a hospitalized patient might be as follows:

7 a.m. June 3, 2017

Give Valium, 5 mg by mouth (PO) at 8 a.m.

J. Glucose, MD

Another type of order that will be encountered is the stat order. This means that a physician gives an order for medication to be administered immediately. This order must also be written and signed by the physician. The most common “stat” order the radiographer will receive will be for an x-ray to be taken, such as in a “stat” mobile chest radiograph.

In the radiographic imaging department, the radiographer frequently assists with medication administration rather than actually giving the drug. If this is the case, after receiving a verbal order from a physician to procure a drug to administer, the radiographer will do the following:

CASE STUDY

A radiographer is preparing a patient for an intrathecal injection prior to a computed tomography (CT) myelogram. She goes to the cupboard in the radiography room where all the contrast media are stored. She selects a particular bottle, gathers the needles and syringe, and informs the radiologist that she is ready for him to come in for the injection. The radiologist draws up the contrast and injects it into the patient’s spinal canal. The patient has his CT myelogram as planned and is sent home.

When the technologist is cleaning the room after the injection, she finds that the bottle will not fit into the sharps container. She then reads the label and discovers that she has used the wrong contrast and that it is NOT for intrathecal injection. She immediately alerts the physician and the supervisor, and the patient is called back. By this time, the patient is already experiencing leg numbness and is having extreme difficulty walking.

The patient is hospitalized, and an attempt is made to withdraw the contrast from the spinal canal. However, with the passage of time, the contrast has already been absorbed into the spinal fluid. The patient is kept hospitalized for several days to make sure that the effects are temporary.

The patient does file a lawsuit against the hospital, the radiologist, the technologist, and the radiology administrator. Through discovery, it is found that the hospital radiology department did not follow The Joint Commission recommendations for storage of contrast media. The radiologic technologist did not read the label before handing it to the physician. Nor did she show the physician the label before he drew up the contrast medium. The physician did not question the radiographer because, having worked with her for many years and having never had an issue with her work, he “trusted her judgment.”

This unfortunate incident can be looked at as simply an accident; however, it is one that could and SHOULD have been prevented. There were many errors that were committed, but they all could have been discovered and prevented if the technologist had simply read the label when she removed it from the shelf.

1. Obtain the drug from the locked drug storage area or the pharmacy location.

2. Verify that it is the correct drug by checking the label before taking it from the area.

3. Obtain the correct supplies for the particular route of administration and prepare the drug; that is, draw it into a syringe or pour it into a glass for oral administration as appropriate and read the label a second time.

4. Put the medication, the package from which it was taken, and other items that will be needed for administration in an area that will be available to the radiologist or other physician.

5. Hold the package (bottle and vial) at the physician’s eye level and state the name and dosage of the drug that has been prepared as the physician prepares to administer the drug. Be sure that the physician reads and acknowledges the drug.

6. Assist the physician to administer the drug to the patient.

7. Document the drug in the correct area.

Every institution will have a slightly different manner of documentation. It is the radiographer’s responsibility to learn the correct method. Whatever the situation, the radiographer is obligated to document on the patient’s chart the name of the drug, the dosage, the route, the time, and the patient’s reaction to any drug that is administered. It may also be necessary to record the drugs administered by the physician and then have the physician sign the entry.

MEDICATION ERRORS

All professional health care workers are responsible for their actions. It is the legal and ethical obligation of all radiographers to be knowledgeable about any drug that they administer. If a drug is incorrectly administered or an order misinterpreted, the radiographer is legally liable. All federal regulations pertaining to controlled substances must be fully understood. The Controlled Substances Act of the federal government restricts personnel who are legally permitted to administer narcotic and hypnotic drugs or any drug that may cause dependence. It also restricts access to these drugs, which should always be kept in a locked area. Documentation and accounting for these drugs are also carefully controlled.

Medication errors are an area of frequent litigation in diagnostic imaging. The radiographer who is administering or assisting with administration of drugs is frequently implicated in this type of litigation (see Case Study). If an error in medication administration is made or if the patient has an adverse reaction to a contrast medium, the radiographer involved must assess the patient’s condition and notify the prescribing physician immediately.

The error or adverse reaction must be included in the patient’s chart. An incident report (sometimes called an unusual occurrence report) will also be required by the facility. A “misadventure” form or a “misadministration” form will also be required. A “misadventure” is one in which the wrong dose or wrong contrast media brought about the same outcome as that expected by the correct drug or correct dosage.

Every detail of the incident must be included in the report, which becomes the property of the department and is not a part of the patient’s medical record. Items to include in the report are:

1. The dosage of the drug administered

2. The name of the incorrect drug

3. Why it was administered

4. The patient’s reaction

5. How the error was remedied

An example of documentation of the wrong contrast administered follows:

Nov. 12, 2013:

08:20 hours Iopamidol 30 mL administered IV. Administered in error instead of Omnipaque.

08:30 hours Dr. Glucophage (radiologist) notified of the error. Initialed by the radiographer.

08:40 hours Dr. Glucophage assessed patient’s condition.

08:45 hours BP 124/70; P 72; R 16. Patient reports no complaints.

The patient must be observed for an appropriate amount of time, and periodic reports on his condition are documented until the patient is discharged from the department. If a drug is administered to the wrong patient, the same procedure is followed. Accurate documentation is the best defense if litigation follows.

METHODS OF DRUG ADMINISTRATION

There are basically three routes by which drugs may be administered: enteral, topical, and parenteral. In what follows, each of these is described, with particular emphasis on the parenteral route.

Enteral Routes

The enteral routes are broken down into oral, sublingual, buccal, and rectal.

Drugs taken by mouth and swallowed into the stomach are said to be given orally. The medical term for this route of administration is PO. It is often the most efficient and most cost-effective method of drug administration. This route is used if the drug will not be destroyed by gastric secretions and when slower absorption and longer duration of drug activity are desired.

A sublingual drug is placed under the tongue and remains there until it is dissolved completely. The patient must not eat or drink until the drug dissolves. It is not to be swallowed or chewed.

A drug administered by the buccal route must be placed against the mucous membranes of the cheek in either the upper or the lower jaw. It must remain there until it dissolves. Drugs given by this route are used for local effect and are drugs such as lozenges.

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